Per ICD-10 guidelines, you would again report S52.222A for an initial encounter. ICD-10-CM defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase.
Contact with other nonpowered hand tool, initial encounter. W27.8XXA is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2018/2019 edition of ICD-10-CM W27.8XXA became effective on October 1, 2018.
This is the American ICD-10-CM version of W29.3 - other international versions of ICD-10 W29.3 may differ. W29.3 describes the circumstance causing an injury, not the nature of the injury.
The ICD-10-CM guidelines define a sequela as “the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” The general coding guidelines in ICD-10-CM for coding of sequelae are essentially the same as coding of late effects in ICD-9-CM and are as follows:
Aftercare codes are found in categories Z42-Z49 and Z51. Aftercare is one of the 16 types of Z-codes covered in the 2012 ICD-10-CM Official Guidelines and Reporting.
ICD-10 code Z71. 89 for Other specified counseling is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
0SHF05ZICD-10-PCS Code 0SHF05Z - Insertion of External Fixation Device into Right Ankle Joint, Open Approach - Codify by AAPC.
W11.XXXAICD-10 code W11. XXXA for Fall on and from ladder, initial encounter is a medical classification as listed by WHO under the range - Other external causes of accidental injury .
ICD-10 code Z51. 81 for Encounter for therapeutic drug level monitoring is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
The patient's primary diagnostic code is the most important. Assuming the patient's primary diagnostic code is Z76. 89, look in the list below to see which MDC's "Assignment of Diagnosis Codes" is first.
Use codes for external fixation only when external fixation is not already listed as part of the basic procedure. Use code 20690 when you apply pins or wires in 1 plane, unilaterally, as an external fixation device. Use code 20692 when you apply a multiplane external fixation system.
Follow-up. The difference between aftercare and follow-up is the type of care the physician renders. Aftercare implies the physician is providing related treatment for the patient after a surgery or procedure. Follow-up, on the other hand, is surveillance of the patient to make sure all is going well.
ICD-10-PCS code 0SPF05Z for Removal of External Fixation Device from Right Ankle Joint, Open Approach is a medical classification as listed by CMS under Lower Joints range.
ICD-10-CM defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase.
D (subsequent encounter) describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery. S (sequela) indicates a complication or condition that arises as a direct result of an injury.
Example 2: A subsequent encounter (character “D”) describes an episode of care during which the patient receives routine care for her or his condition during the healing or recovery phase.
The ‘S’ is added only to the injury code, not the sequela code. The seventh character ‘S’ identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”.
There is no time limit on when a sequela code can be used. The residual effect may be present early or may occur months or years later. Two codes are generally required: one describing the nature of the sequela and one for the sequela. The code for the acute phase of the illness or injury is never reported with a code for the late effect.
ICD-10-CM says the seventh character S is “for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” In other words, sequela are the late effects of an injury.#N#Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain. Some patients might never have been treated for the injury at all. As time passes, the pain becomes intolerable and the patient seeks a pain remedy.#N#A late effect can occur only after the acute phase of the injury or illness has passed; therefore, you cannot report a code for the acute illness and a code for the late effect at the same encounter, for the same patient. The only exception occurs if both conditions exist (for example, the patient has a current cerebrovascular condition and deficits from an old cerebrovascular condition).#N#When reporting sequela (e), you usually will need to report two codes. The first describes the condition or nature of the sequela (e) and second the second describes the sequela (e) or “late effect.” For example, you may report M81.8 Other osteoporosis without current pathological fracture with E64.8 Sequelae of other nutritional deficiencies (calcium deficiency).#N#If a late effect code describes all of the relevant details, you should report that one code, only (e.g., I69.191 Dysphagia following nontraumatic intracerebral hemorrhage ).#N#For example: A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.
ICD-10-CM defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.”#N#A seventh character “D” is appropriate during the recovery phase, no matter how many times he has seen the provider for this problem, previously.#N#Note that ICD-10-CM guidelines do not definitively establish when “active treatment” becomes “routine care.” Active treatment occurs when the provider sees the patient and develops a plan of care. When the patient is following the plan, that is subsequent. If the provider needs to adjust the plan of care—for example, if the patient has a setback or must returns to the OR—the care becomes active, again.
In other words, sequela are the late effects of an injury. Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain. Some patients might never have been treated for the injury at all.
A late effect can occur only after the acute phase of the injury or illness has passed; therefore, you cannot report a code for the acute illness and a code for the late effect at the same encounter, for the same patient.
The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury.